16. Post Menopausal Bleeding

Question 1

What is the World Health Organization’s definition of menopause?

Answer 1

The menopause is defined as the cessation of menses for a period of one year, marking the end of a woman’s reproductive life

Question 2

What is the median age of menopause?

Answer 2

The median age of menopause is 51 years.

Question 3

What causes menopause?

Answer 3

Menopause correlates with a decline in ovarian function and a decrease in oestrogen secretion.

Question 4

Should postmenopausal bleeding (PMB) be investigated?

Answer 4

Yes, postmenopausal bleeding should always be investigated as it is considered abnormal.

Question 5

When is postmenopausal bleeding acceptable?

Answer 5

PMB is only acceptable in women with a uterus in situ who are placed on sequential hormone replacement therapy (HRT), involving oestrogen followed by progesterone, which causes a withdrawal bleed.

Question 6

What is the most important reason to investigate postmenopausal bleeding?

Answer 6

Although not the leading cause, the most important reason to investigate PMB is to exclude underlying gynaecological malignancy, particularly cervical and uterine cancer

Question 7

At what age should postmenopausal bleeding be investigated?

Answer 7

PMB should be investigated in any woman over the age of 40 years, as well as in all cases of postmenopausal bleeding.

Question 8

What is the most common cause of postmenopausal bleeding?

Answer 8

The most common cause is atrophy of the genital tract due to decreased oestrogen secretion, accounting for 60-80% of cases.

Question 9

Causes of PMB

Answer 9

1. Atrophy
2. Genital malignancies
3. Polyps
4. Endometrial hyperplasia
5. Iatrogenic
6. Trauma
7. Infections

Question 10

What are the main genital malignancies that can cause postmenopausal bleeding?

Answer 10

• Cervical cancer
• Endometrial cancer
• Ovarian or fallopian tube cancer (may present with an offensive bloody discharge)
• Vulval cancer
• Vaginal cancer

Question 11

What percentage of postmenopausal bleeding cases are caused by polyps?

Answer 11

Polyps account for 2-12% of cases.

Question 12

What role does endometrial hyperplasia play in postmenopausal bleeding?

Answer 12

Endometrial hyperplasia is responsible for 5-10% of cases of PMB.

Question 13

How can hormone therapy contribute to postmenopausal bleeding?

Answer 13

Iatrogenic causes, such as hormone therapy or exogenous oestrogen, can lead to PMB.

Question 14

What other causes of postmenopausal bleeding should be considered?

Answer 14

Trauma
Infections (e.g., cervicitis, vaginal inflammation)

Question 15

What are some rarer causes of postmenopausal bleeding?

Answer 15

Rarer causes include systemic disorders like bleeding disorders (e.g., Von Willebrand’s disease, thrombocytopaenia, liver disease).

Question 16

What is the approach to diagnosing and treating postmenopausal bleeding (PMB)?

Answer 16

The diagnosis and treatment of PMB involve a thorough history, clinical examination, routine/bedside investigations, and special investigations.

Question 17

What key factors should be considered when taking a history for PMB?

Answer 17

• Onset of bleeding
• Use of drugs or exogenous oestrogens
• Precipitating factors for the bleeding
• Associated symptoms, including signs of anaemia
• Medical history and medications (e.g., anticoagulants)

Question 18

What should be included in the general examination for PMB?

Answer 18

General examination (looking for pallor, lymphadenopathy, and risk factors such as obesity)

Thyroid and breast examination

Question 19

What abdominal examination should be done in cases of PMB?

Answer 19

Abdominal inspection, palpation, and auscultation to assess for tenderness, masses, or ascites.

Question 20

What specific pelvic examinations are necessary for investigating PMB?

Answer 20

• Visualisation of the lower genital tract using a speculum
• Bimanual examination
• Rectal examination

Question 21

What should you ask to confirm the source of bleeding during a pelvic examination?

Answer 21

1. Is the bleeding from the genital tract, or could it be from the urinary or gastrointestinal tract? (Patients may be uncertain, so it’s important to perform a urine dipstick and rectal exam).
2. If the bleeding is from the genital tract, is it from the lower genital tract (vulva, vagina, cervix)? This requires careful visualisation of the lower genital tract using a speculum and inspection of the vulva, peri-urethral, and peri-anal areas.
3. If the bleeding is not from the lower genital tract, could it be from the upper genital tract (uterus, tubes, ovaries)? To assess this, a bimanual and pelvi-rectal examination is essential.

Question 22

What are the routine investigations for postmenopausal bleeding (PMB)?

Answer 22

Routine investigations include:

• Hemoglobin or full blood count to exclude anaemia
• Urine dipstick
• Papanicolaou (Pap) smear if a normal cervix is seen on speculum examination

Question 23

What should be done if an abnormality is seen on the cervix during examination?

Answer 23

Any abnormality seen on the cervix should be biopsied.

Question 24

Is endometrial sampling important for postmenopausal bleeding?

Answer 24

Yes, ideally all women with PMB should have endometrial sampling for histological evaluation.

Question 25

What is the gold standard for assessing the endometrium in postmenopausal bleeding?

Answer 25

The gold standard is hysteroscopy, as it allows visualization of the entire endometrial cavity and directed biopsy of any irregular areas.

Question 26

What are alternative methods for histological evaluation of the endometrium?

Answer 26

Alternative methods include:

Pipelles
Accurettes
These are 90-98% accurate but are blind sampling methods.

Question 27

What role does transvaginal ultrasound play in postmenopausal bleeding?

Answer 27

Transvaginal ultrasound is used as a triage tool to assess the endometrium, but it is not definitive for diagnosis.

Question 28

What should be done if the endometrial sample is inadequate or suboptimal?

Answer 28

If the endometrial sample is inadequate, an endometrial thickness (ET) measurement of ≤4 mm is reassuring as it suggests atrophy. If the ET is >4 mm, a hysteroscopy should be performed to exclude polyps and malignancy.

Question 29

Why is histology more reassuring than ultrasound when the endometrial thickness (ET) is greater than 4 mm?

Answer 29

Type 2 uterine cancers can develop on the background of atrophy, so histological evaluation is more reliable than a thin endometrial thickness on ultrasound.

Question 30

What is the first step in treating postmenopausal bleeding

Answer 30

The first step is to resuscitate and optimize the patient medically if necessary.

Question 31

How is atrophy of the genital tract treated in postmenopausal bleeding?

Answer 31

• Atrophy can be treated with topical hormonal creams
• Hormone treatment
• Lubricants for sexual intercourse

Question 32

How are polyps treated in postmenopausal bleeding

Answer 32

Polyps can be resected hysteroscopically.

Question 33

How should cervical cancer and uterine cancer be managed?

Answer 33

Patients with cervical or uterine cancer must be referred to a gynaecology oncology unit for appropriate staging and treatment

Question 34

How is simple endometrial hyperplasia treated?

Answer 34

Simple hyperplasia can be managed with progestin treatment, including:

• Oral progestins
• Intramuscular depot injections
• Mirena intra-uterine system (IUS)

Question 35

How is complex hyperplasia with atypia treated?

Answer 35

• Ideally managed surgically with a hysterectomy and bilateral salpingo-oophorectomy, along with a frozen section.
• Complex hyperplasia with atypia is a premalignant lesion, and up to 30% may progress to endometrial carcinoma.
• If the patient is not fit for surgery, progestin therapy or a Mirena IUS can be used, along with repeat hysteroscopic sampling.

Question 36

What is the most common cause of postmenopausal bleeding in developing countries?

Answer 36

Cervical cancer is the most common cause of postmenopausal bleeding in developing countries with poor socioeconomics, primarily due to the lack of a well-functioning, organized national cervical cancer screening program.

Question 37

What is the most common cause of postmenopausal bleeding in developed countries?

Answer 37

In developed countries with effective cervical cancer screening programs, uterine cancer predominates as the leading cause of postmenopausal bleeding.